Retrospective evaluations of repeated head injury are needed to better understand associations between head injury exposure and later-life deleterious outcomes. However, there is limited assessment of whether head injury recall assessments produce consistent measures over time, and no assessment of whether the reporting is related to current health status. The concussion signs and symptoms scale (CSS; developed for the Football Players Health Study at Harvard University) was designed to measure cumulative head injury exposure history by asking about the frequency of 10 CSS during active football play. Responses are summed with a total CSS range of 0-130. Former professional American-style football players completed the CSS at two timepoints. A subset of participants also reported on current health (subjective cognitive symptoms [Quality of Life in Neurological Disorders], depression [Patient Health Questionnaire], anxiety [Generalized Anxiety Disorder], pain [Patient-Reported Outcome Measurement Information System (PROMIS) Global], and overall health [PROMIS Global]) at each timepoint. To examine reporting consistency and recall bias, we calculated the Spearman correlation between measures assessed an average of 74.5 (standard deviation [SD] = 41.2) months apart and estimated associations between change in demographic, football-related, and current health factors and change in CSS (ΔCSS) over time using multivariable linear regression. Across the 335 participants, the mean (SD) CSS score at times 1 and 2 were 30.2 (25.5) and 29.1 (25.2), respectively, with an average change in CSS (ΔCSS) of -1.1 (SD = 19.8). There was no significant association between ΔCSS and years since play, months between timepoints, or age at time 1 (0.49 < p < 0.84). Eighty-one (24.2%) participants completed identical questions on current health factors at times 1 and 2. In separate multivariable models, there was no association between changes in pain, cognitive symptoms, health, depression, and anxiety reporting and ΔCSS (0.17 < p < 0.92). On average, the CSS score as a measure of retrospective concussion exposure did not change meaningfully over an average of 75 months, and changes in current health status were not significantly associated with ΔCSS. Results suggest that the CSS scale is stable over time and appears robust against changes in health status. The CSS should be considered for other retrospective studies of brain-injured populations to measure prior cumulative concussion history.

Introduction:American-style football (ASF) has been linked to chronic adverse health outcomes. The extent to which ASF players' careers impact their spouses' caregiver burden, depression, and anxiety remains unknown. In addition to conventional family stressors, ASF families may have specific concerns such as chronic traumatic encephalopathy (CTE; a condition that can only be established at autopsy), which may additionally contribute to caregiver burden and mood symptoms. Methods:Family Experiences Managing Football Lives (FEM-FL) is a cross-sectional study developed under the Football Players Health Study at Harvard University. Eligible participants were partners of current and former professional ASF players who completed electronic surveys from 2021 to 2024. Data on age, race, family composition, income, employment status, caregiver help, personal health, marital satisfaction, player position, and number of relocations were collected. Participants were asked whether they believed their partner had "CTE." Multivariable models measured associations between established and ASF-specific risk factors and caregiver burden (Zarit 4-item Burden Interview), and depression and anxiety symptoms (Patient Health Questionnaire-4). Results:Among 153 partners of active and former professional ASF players, mean [SD] age was 48.1 [13.5], and 28.8% self-identified as Black. In models that adjusted for established risk factors and ASF-specific variables, poor health among partners was associated with a 1.6 point increase in depression score (95% CI = 0.90, 2.30; p < 0.001) and 1.87 point increase in anxiety (95% CI = 1.05, 2.69; p < 0.001). Models that controlled for established risk factors identified significant associations between increased marital satisfaction and a 5.87 reduction in caregiver burden score (95% CI= -7.32, -4.43; p < 0.001), 1.26 score reduction in depression score (95% CI = -1.75, -0.77; p < 0.001) and 1.32 reduction in anxiety score (95% CI = -1.89, -0.75; p < 0.001). CTE concerns were associated with a 2.90 increase in caregiver burden score (95% CI = 1.78, 3.99; p < 0.001) and a 0.44 increase in reported anxiety (95% CI = -0.01, 0.88; p = 0.05), but had no association with depression in adjusted models. Discussion:Among partners of active and former professional ASF players, marital satisfaction, poor health, and concerns about CTE may play a role in caregiver burden and behavioral health. CTE concerns represents a potential novel risk factor for increased caregiver burden among partners of ASF players.

ImportanceParticipation in American-style football (ASF) has been linked to chronic traumatic encephalopathy neuropathological change (CTE-NC), a specific neuropathologic finding that can only be established at autopsy. Despite being a postmortem diagnosis, living former ASF players may perceive themselves to have CTE-NC. At present, the proportion and clinical correlates of living former professional ASF athletes with perceived CTE who report suicidality are unknown.ObjectiveTo determine the proportion, clinical correlates, and suicidality of living former professional ASF players with perceived CTE.Design, Setting, and ParticipantsA cross-sectional study within the Football Players Health Study at Harvard University was conducted from 2017 to 2020. Using electronic and paper surveys, this population-based study included former ASF players who contracted with a professional league from 1960 to 2020 and volunteered to fill out a baseline survey. Data for this study were analyzed from June 2023 through March 2024.ExposuresData included demographics, football-related exposures (eg, position, career duration), and current health problems (anxiety, attention-deficit/hyperactivity disorder, depression, diabetes, emotional and behavioral dyscontrol symptoms, headache, hyperlipidemia, hypertension, low testosterone level, pain, sleep apnea, and subjective cognitive function).Main Outcomes and MeasuresThe proportion of participants reporting perceived CTE. Univariable and multivariable models were used to determine clinical and suicidality correlates of perceived CTE.ResultsAmong 4180 former professional ASF players who volunteered to fill out a baseline survey, 1980 (47.4%) provided follow-up data (mean [SD] age, 57.7 [13.9] years). A total of 681 participants (34.4%) reported perceived CTE. Subjective cognitive difficulties, low testosterone level, headache, concussion signs and symptoms accrued during playing years, depressive/emotional and behavioral dyscontrol symptoms, pain, and younger age were significantly associated with perceived CTE. Suicidality was reported by 171 of 681 participants with perceived CTE (25.4%) and 64 of 1299 without perceived CTE (5.0%). After adjusting for established suicidality predictors (eg, depression), men with perceived CTE remained twice as likely to report suicidality (odds ratio, 2.06; 95% CI, 1.36-3.12; P < .001).Conclusions and RelevanceThis study found that approximately one-third of living former professional ASF players reported perceived CTE. Men with perceived CTE had an increased prevalence of suicidality and were more likely to have health problems associated with cognitive impairment compared with men without perceived CTE. Perceived CTE represents a novel risk factor for suicidality and, if present, should motivate the diagnostic assessment and treatment of medical and behavioral conditions that may be misattributed to CTE-NC.

American-style football (ASF) players experience repetitive head impacts that may result in chronic traumatic encephalopathy neuropathological change (CTE-NC). At present, a definitive diagnosis of CTE-NC requires the identification of localized hyperphosphorylated Tau (p-Tau) after death via immunohistochemistry. Some studies suggest that positron emission tomography (PET) with the radiotracer [18F]-Flortaucipir (FTP) may be capable of detecting p-Tau and thus establishing a diagnosis of CTE-NC among living former ASF players. To assess associations between FTP, football exposure, and objective neuropsychological measures among former professional ASF players, we conducted a study that compared former professional ASF players with age-matched male control participants without repetitive head impact exposure. Former ASF players and male controls underwent structural magnetic resonance imaging and PET using FTP for p-Tau and [11C]-PiB for amyloid-β. Former players underwent neuropsychological testing. The ASF exposure was quantified as age at first exposure, professional career duration, concussion signs and symptoms burden, and total years of any football play. Neuropsychological testing included measures of memory, executive functioning, and depression symptom severity. P-Tau was quantified as FTP standardized uptake value ratios (SUVR) and [11C]-PiB by distribution volume ratios (DVR) using cerebellar grey matter as the reference region. There were no significant differences in [18F]-FTP uptake among former ASF players (n = 27, age = 50 ± 7 years) compared with control participants (n = 11, age = 55 ± 4 years), nor did any participant have significant amyloid-β burden. Among ASF participants, there were no associations between objective measures of neurocognitive functioning and [18F]-FTP uptake. There was a marginally significant difference, however, between [18F]-FTP uptake isolated to the entorhinal cortex among players in age-, position-, and race-adjusted models (p = 0.05) that may represent an area of future investigation. The absence of increased [18F]-FTP uptake in brain regions previously implicated in CTE among former professional ASF players compared with controls questions the utility of [18F]-FTP PET for clinical evaluation in this population.

Background: Despite the potential protective effect of a plant-based diet against chronic obstructive pulmonary disease (COPD), it remains unknown whether intake of different types of plant foods is beneficial for COPD. Our aims were to determine whether adherence to the healthful version of a plant-based diet (healthful Plant-based Diet Index (hPDI)) is associated with a lower COPD risk, whereas adherence to the unhealthful version (unhealthful Plant-based Diet Index (uPDI)) is associated with a higher COPD risk. Methods: 46,948 men from the Health Professionals Follow-up Study, 73,592 women from the Nurses’ Health Study, and 85,515 women from the Nurses’ Health Study II who completed biennial questionnaires from 1984–2018. We derived diet scores from repeated validated food frequency questionnaires. Among 5,661,994 person-years of follow-up, we documented 2605 validated COPD cases between 1984–2018. Results: After tight control for smoking and other potential confounders, COPD risk was 46% lower among participants with the highest hPDI score compared to those with the lowest score. Conversely, COPD risk was 39% higher among participants with the highest uPDI. Further adjustment for processed meat intake led to similar results. Conclusions: These findings provide further evidence for consuming a diet that emphasizes healthful plant foods to optimize lung health.

HomeCirculationVol. 147, No. 14Association Between Concussion Burden During Professional American-Style Football and Postcareer Hypertension No AccessLetterRequest AccessFull TextAboutView Full TextView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toNo AccessLetterRequest AccessFull TextAssociation Between Concussion Burden During Professional American-Style Football and Postcareer Hypertension Rachel Grashow, Can Ozan Tan, Saef Izzy, Herman A. Taylor Jr, Marc G. Weisskopf, Meagan M. Wasfy, Alicia J. Whittington, Frank Speizer, Ross Zafonte and Aaron L. Baggish Rachel GrashowRachel Grashow https://orcid.org/0000-0001-6961-0243 Harvard University, Harvard Medical School, Boston, MA (R.G., H.A.T., M.G.W., M.M.W., A.J.W., F.S., R.Z., A.L.B.). Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA (R.G., M.G.W., F.S.). , Can Ozan TanCan Ozan Tan Department of Electrical Engineering, Mathematics, and Computer Science, University of Twente, The Netherlands (C.O.T.). , Saef IzzySaef Izzy Department of Neurology, Divisions of Stroke, Cerebrovascular, and Critical Care Neurology (S.I.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA. , Herman A. Taylor JrHerman A. Taylor Jr Harvard University, Harvard Medical School, Boston, MA (R.G., H.A.T., M.G.W., M.M.W., A.J.W., F.S., R.Z., A.L.B.). Cardiovascular Research Institute, Morehouse School of Medicine, Atlanta, GA (H.A.T.). , Marc G. WeisskopfMarc G. Weisskopf Harvard University, Harvard Medical School, Boston, MA (R.G., H.A.T., M.G.W., M.M.W., A.J.W., F.S., R.Z., A.L.B.). Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA (R.G., M.G.W., F.S.). , Meagan M. WasfyMeagan M. Wasfy Harvard University, Harvard Medical School, Boston, MA (R.G., H.A.T., M.G.W., M.M.W., A.J.W., F.S., R.Z., A.L.B.). Cardiovascular Performance Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA (M.M.W., A.L.B.). , Alicia J. WhittingtonAlicia J. Whittington https://orcid.org/0000-0001-5075-3033 Harvard University, Harvard Medical School, Boston, MA (R.G., H.A.T., M.G.W., M.M.W., A.J.W., F.S., R.Z., A.L.B.). , Frank SpeizerFrank Speizer Harvard University, Harvard Medical School, Boston, MA (R.G., H.A.T., M.G.W., M.M.W., A.J.W., F.S., R.Z., A.L.B.). Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA (R.G., M.G.W., F.S.). Channing Division of Network Medicine (F.S.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA. , Ross ZafonteRoss Zafonte Harvard University, Harvard Medical School, Boston, MA (R.G., H.A.T., M.G.W., M.M.W., A.J.W., F.S., R.Z., A.L.B.). Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, MA (R.Z.). and Aaron L. BaggishAaron L. Baggish Correspondence to: Aaron L. Baggish, MD, Cardiovascular Performance Program, Massachusetts General Hospital, 55 Fruit Street, Yawkey Suite 5B, Boston, MA 02114. Email E-mail Address: [email protected] https://orcid.org/0000-0003-2042-1489 Harvard University, Harvard Medical School, Boston, MA (R.G., H.A.T., M.G.W., M.M.W., A.J.W., F.S., R.Z., A.L.B.). Cardiovascular Performance Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA (M.M.W., A.L.B.). Department of Cardiology, Lausanne University Hospital and Institute for Sport Science, University of Lausanne, Switzerland (A.L.B.). Originally published7 Feb 2023https://doi.org/10.1161/CIRCULATIONAHA.122.063767Circulation. 2023;147:1112–1114FootnotesFor Sources of Funding and Disclosures, see page 1114.Circulation is available at www.ahajournals.org/journal/circCorrespondence to: Aaron L. Baggish, MD, Cardiovascular Performance Program, Massachusetts General Hospital, 55 Fruit Street, Yawkey Suite 5B, Boston, MA 02114. Email [email protected]harvard.eduReferences1. Weiner RB, Wang F, Isaacs SK, Malhotra R, Berkstresser B, Kim JH, Hutter AM, Picard MH, Wang TJ, Baggish AL. Blood pressure and left ventricular hypertrophy during American-style football participation.Circulation. 2013; 128:524–531. doi: 10.1161/CIRCULATIONAHA.113.003522LinkGoogle Scholar2. Tucker AM, Vogel RA, Lincoln AE, Dunn RE, Ahrensfield DC, Allen TW, Castle LW, Heyer RA, Pellman EJ, Strollo PJ, et al. Prevalence of cardiovascular disease risk factors among National Football League players.JAMA. 2009; 301:2111–2119. doi: 10.1001/jama.2009.716CrossrefMedlineGoogle Scholar3. Izzy S, Chen PM, Tahir Z, Grashow R, Radmanesh F, Cote DJ, Yahya T, Dhand A, Taylor H, Shih SL, et al. Association of traumatic brain injury with the risk of developing chronic cardiovascular, endocrine, neurological, and psychiatric disorders.JAMA Netw Open. 2022; 5:e229478. doi: 10.1001/jamanetworkopen.2022.9478CrossrefMedlineGoogle Scholar4. Grashow R, Weisskopf MG, Miller KK, Nathan DM, Zafonte R, Speizer FE, Courtney TK, Baggish A, Taylor HA, Pascual-Leone A, et al. Association of concussion symptoms with testosterone levels and erectile dysfunction in former professional US-style football players.JAMA Neurol. 2019; 76:1428–1438. doi: 10.1001/jamaneurol.2019.2664CrossrefMedlineGoogle Scholar5. Knopman D, Boland LL, Mosley T, Howard G, Liao D, Szklo M, McGovern P, Folsom AR; Atherosclerosis Risk in Communities (ARIC) Study Investigators. Cardiovascular risk factors and cognitive decline in middle-aged adults.Neurology. 2001; 56:42–48. doi: 10.1212/wnl.56.1.42CrossrefMedlineGoogle Scholar eLetters(0)eLetters should relate to an article recently published in the journal and are not a forum for providing unpublished data. Comments are reviewed for appropriate use of tone and language. Comments are not peer-reviewed. Acceptable comments are posted to the journal website only. Comments are not published in an issue and are not indexed in PubMed. Comments should be no longer than 500 words and will only be posted online. References are limited to 10. Authors of the article cited in the comment will be invited to reply, as appropriate.Comments and feedback on AHA/ASA Scientific Statements and Guidelines should be directed to the AHA/ASA Manuscript Oversight Committee via its Correspondence page.Sign In to Submit a Response to This Article Previous Back to top Next FiguresReferencesRelatedDetails April 4, 2023Vol 147, Issue 14 Advertisement Article InformationMetrics © 2023 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.122.063767PMID: 36748510 Originally publishedFebruary 7, 2023 Keywordshypertensiontraumaticbrain injuriessportsathletesPDF download Advertisement SubjectsHigh Blood PressureHypertension

BackgroundParticipation in American-style football (ASF), one of the most popular sports worldwide, has been associated with adverse health outcomes. However, prior clinical studies of former ASF players have been limited by reliance on subjective self-reported data, inadequate sample size, or focus on a single disease process in isolation.ObjectiveTo determine the burden of objective multi-system pathology and its relationship with subjective health complaints among former professional ASF players.MethodsThe In-Person Assessment is a case-control, multi-day, deep human phenotyping protocol designed to characterize and quantify pathology among former professional ASF players. Participants, recruited from an on-going large-scale longitudinal cohort study, will include 120 men who report either no health conditions, a single health condition, or multiple health conditions across the key domains of cardiometabolic disease, disordered sleep, chronic pain, and cognitive impairment. Data will be collected from validated questionnaires, structured interviews, physical examinations, multi-modality imaging, and functional assessments over a 3-day study period. A pilot study was conducted to assess feasibility and to obtain participant feedback which was used to shape the final protocol.ResultsThis study provides a comprehensive assessment of objective multi-system pathology and its relationship with subjective health complaints among former professional ASF players.ConclusionThe study will determine whether subjective health complaints among former professional ASF players are explained by objective explanatory pathology and will provide novel opportunities to examine the interrelatedness of co-morbidities. It is anticipated that this protocol will be applicable to other clinical and occupational populations.

IMPORTANCE Increased risk of neurological and psychiatric conditions after traumatic brain injury (TBI) is well-defined. However, cardiovascular and endocrine comorbidity risk after TBI in individuals without these comorbidities and associations with post-TBI mortality have received little attention. OBJECTIVE To assess the incidence of cardiovascular. endocrine, neurological, and psychiatric comorbidities in patients with mild TBI (mTBI) or moderate to severe TBI (msTBI) and analyze associations between post-TBI comorbidities and mortality. DESIGN, SETTING, AND PARTICIPANTS This prospective longitudinal cohort study used hospital-based patient registry data from a tertiary academic medical center to select patients without any prior clinical comorbidities who experienced TBI from 2000 to 2015. Using the same data registry, individuals without head injuries, the unexposed group, and without target comorbidities were selected and age-, sex-, and race-frequency-matched to TBI subgroups. Patients were followed-up for up to 10 years. Data were analyzed in 2021. EXPOSURES Mild or moderate to severe head trauma. MAIN OUTCOMES AND MEASURES Cardiovascular, endocrine, neurologic, and psychiatric conditions were defined based on International Classification of Diseases, Ninth Revision (ICD-9) or International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10). Associations between TBI and comorbidities, as well as associations between the comorbidities and mortality, were analyzed. RESULTS A total of 4351 patients with mTBI (median [IQR] age, 45 [29-57] years), 4351 patients with msTBI (median [IQR] age, 47 [30-58] years), and 4351 unexposed individuals (median [1012] age, 46 [30-58] years) were included in analyses. In each group, 45% of participants were women. mTBI and msTBl were significantly associated with higher risks of cardiovascular, endocrine, neurologic, and psychiatric disorders compared with unexposed individuals. In particular, hypertension risk was increased in both mTBI (HR, 2.5; 95% CI, 2.1-2.9) and msTBI (HR, 2.4; 95% CI, 2.0-2.9) groups. Diabetes risk was increased in both mTBI (HR, 1.9; 95% CI, 1.4.2.7) and msTBl (HR, 1.9; 95% CI, 1.4-2.6) groups, and risk of ischemic stroke or transient ischemic attack was also increased in mTBI (HR, 2.2; 95% CI, 1.4-3.3) and msTBl (HR, 3.6; 95% CI, 2.4-5.3) groups. All comorbidities in the TBI subgroups emerged within a median (IQR) of 3.49 (1.76-5.96) years after injury. Risks for post-TBI comorbidities were also higher in patients aged 18 to 40 years compared with age-matched unexposed individuals: hypertension risk was increased in the mTBI (HR, 5.9; 95% CI, 3.9-9.1) and msTBl (HR, 3.9; 95% CI, 2.5-6.1) groups, while hyperlipidemia (HR, 2.3; 95% CI, 1.5-3.4) and diabetes (HR, 4.6; 95% CI, 2.1-9.9) were increased in the mTBI group. Individuals with msTBI, compared with unexposed patients, had higher risk of mortality (432 deaths [9.9%] vs 250 deaths [5.7%]; P < .001); postinjury hypertension (HR, 1.3; 95% CI, 1.1-1.7), coronary artery disease (HR, 2.2; 95% CI, 1.6-3.0), and adrenal insufficiency (HR, 6.2; 95% CI, 2.8-13.0) were also associated with higher mortality. CONCLUSIONS AND RELEVANCE These findings suggest that TBI of any severity was associated with a higher risk of chronic cardiovascular, endocrine, and neurological comorbidities in patients without baseline diagnoses. Medical comorbidities were observed in relatively young patients with TBI. Comorbidities occurring after TBI were associated with higher mortality. These findings suggest the need for a targeted screening program for multisystem diseases after TBI, particularly chronic cardiometabolic diseases.

OBJECTIVE:To examine the relationships between age, healthspan and chronic illness among former professional American-style football (ASF) players. METHODS:We compared age-specific race-standardised and body mass index-standardised prevalence ratios of arthritis, dementia/Alzheimer's disease, hypertension and diabetes among early adult and middle-aged (range 25-59 years) male former professional ASF players (n=2864) with a comparator cohort from the National Health and Nutrition Examination Survey and National Health Interview Survey, two representative samples of the US general population. Age was stratified into 25-29, 30-39, 40-49 and 50-59 years. RESULTS:Arthritis and dementia/Alzheimer's disease were more prevalent among ASF players across all study age ranges (all p<0.001). In contrast, hypertension and diabetes were more prevalent among ASF players in the youngest age stratum only (p<0.001 and p<0.01, respectively). ASF players were less likely to demonstrate intact healthspan (ie, absence of chronic disease) than the general population across all age ranges. CONCLUSION:These data suggest the emergence of a maladaptive early ageing phenotype among former professional ASF players characterised by premature burden of chronic disease and reduced healthspan. Additional study is needed to investigate these findings and their impact on morbidity and mortality in former ASF players and other athlete groups.

While chronic neurological effects from concussion have been studied widely, little is known about possible links between concussion and long-term medical and behavioral comorbidities. We performed a retrospective cohort study of 9205 adult patients with concussion, matched to non-concussion controls from a hospital-based electronic medical registry. Patients with comorbidities before the index visit were excluded. Behavioral and medical comorbidities were defined by International Classification of Diseases, Ninth and Tenth Revision codes. Groups were followed for up to 10 years to identify comorbidity incidence after a concussion. Cox proportional hazards models were used to calculate associations between concussion and comorbidities after multi-variable adjustment. Patients with concussion were 57% male (median age: 31; interquartile range [IQR] = 23-48 years) at enrollment with a median follow-up time of 6.1 years (IQR = 4.2-9.1) and well-matched to healthy controls. Most (83%) concussions were evaluated in outpatient settings (5% inpatient). During follow-up, we found significantly higher risks of cardiovascular risks developing including hypertension (hazard ratio [HR] = 1.7, 95% confidence interval [CI]: 1.5-1.9), obesity (HR = 1.7, 95% CI: 1.3-2.0), and diabetes mellitus (HR = 1.8, 95% CI: 1.4-2.3) in the concussion group compared with controls. Similarly, psychiatric and neurological disorders such as depression (HR = 3.0, 95% CI: 2.6-3.5), psychosis (HR = 6.0, 95% CI: 4.2-8.6), stroke (HR = 2.1 95% CI: 1.5-2.9), and epilepsy (HR = 4.4, 95% CI: 3.2-5.9) were higher in the concussion group. Most comorbidities developed less than five years post-concussion. The risks for post-concussion comorbidities were also higher in patients under 40 years old compared with controls. Patients with concussion demonstrated an increased risk of development of medical and behavioral health comorbidities. Prospective studies are warranted to better describe the burden of long-term comorbidities in patients with concussion.

BACKGROUND:Former American style football players (ASF players) have recognized health concerns associated with prior sport participation. It remains unknown whether categorizations of current health conditions, referred to in this report as afflictions (conceptually framed as neurocognitive, cardiovascular, cardiometabolic, sleep apnea, and chronic pain) are associated with physical and mental function.OBJECTIVE:To evaluate the association of afflictions to physical and mental function. It was hypothesized that former National Football League players with any affliction would have worse function compared to unafflicted participants. It was anticipated that multiple afflictions would result in cumulative loss of function.DESIGN:Cross-sectional retrospective design.SETTING:Academic medical multisite hospital system.PARTICIPANTS:A total of 3913 of 15,611 former ASF players who played professionally from 1960 to 2019 (response rate 25%). Assessment of Risk Factors Self-report survey.MAIN OUTCOME MEASURES:Each participant completed the Patient Reported Outcomes Measurement Information System (PROMIS) Global Health Scale and Physical Function questionnaires. Responses were used to generate two physical function and one mental function subscale scores. Raw scores were converted to T-scores categorized as impaired (T-score < 40) or unimpaired (T-score ≥ 40). Primary analyses measured the association of affliction to function (impaired or unimpaired).RESULTS:After adjusting for confounders (age, race, position, number of seasons, age of first exposure to football, alcohol use, smoking history, and current body mass index), each affliction was associated with reduced physical function on the Global physical function subscale (risk ratio [RR] = 1.23-2.45, all P < .005), physical function scale (RR = 1.24-2.75, all P < .01), and mental function scale (RR = 1.34-2.87, all P < .001), except that cardiovascular affliction was not associated with mental function (RR = 1.15, P = .15). The lowest functional measures were observed in those afflicted by chronic pain. Cumulative afflictions were associated with worse function.CONCLUSIONS:Afflictions are associated with cumulative reduction of function. Research evaluating how afflictions interact may help elucidate mechanisms for illness and develop interventions to optimize function.

Recent attention to consequences of head trauma among former professional American-style football players has increased the likelihood that former players and their healthcare providers attribute neurocognitive effects to these exposures. In addition to head trauma, however, many potentially modifiable risk factors are associated with cognitive impairment. We examined the association of self-reported risk factors for cognitive impairment (e.g., cardiovascular health, sleep, pain, depression, anxiety, smoking, physical impairment, and physical activity) with cognition-related quality of life, measured by the Quality of Life in Neurological Disorders, Applied Cognition-General Concerns (Neuro-QOL) among 3803 former National Football League (NFL) players. We examined the prevalence of risk factors among men who had experienced a high number of concussion symptoms during playing years, comparing men with good current cognition-related QOL, the "healthy concussed," to men with poor cognition-related QOL, the "unhealthy concussed." Physical functioning, pain, depression, and anxiety were very strongly associated with poor cognitive-related QOL (risk ratio range, 2.21-2.70, p < 0.0001 for all). Short sleep duration and low physical activity were also strongly associated (RR = 1.69 and 1.57, respectively, p < 0.0001 for both). The largest differences between healthy and unhealthy concussed were in chronic pain (72.0% vs. 21.2%), depressive symptoms (50.3% vs. 6.3%), anxiety symptoms (53.4% vs. 11.6%), and physical impairment (52.4% vs. 12.5%). Substantial differences also existed in prevalence of sleep apnea, short sleep duration, high-intensity exercise, weight training, high blood pressure, and body mass index ≥35 kg/m2 (all differences >10 percentage points). We identified cognitive risk factors, including chronic pain, mood problems, sleep problems, obesity, and lack of exercise, that were commonly present in former football players with cognition-related impairment. Better treatment for these factors may reduce cognitive problems in this population.

PURPOSE:Race differences in health are pervasive in the United States. American-style football players are a racially diverse group with social status and other benefits that may reduce health disparities. Whether race disparities in health exist among former professional football players, and whether they differ by era of play, is unknown. METHODS:We examined the association of self-reported race with health outcomes (e.g., physical and cognitive function, pain, depression, and anxiety), among 3747 participants in the Football Players Health Study, comprising former National Football League players who played since 1960. We conducted analyses stratified by age. RESULTS:Black players had increased risk of all five adverse health outcomes versus white players (risk ratio range = 1.36 to 1.89). Native Hawaiians and men of other races had greater risk of all health outcomes except impaired physical functioning, compared with white players (risk ratio range = 1.25 to 1.64). No clear patterns were observed by era of play. In general, race disparities were not accounted for by health-related exposures during playing years. Adjustment for current BMI somewhat attenuated associations. CONCLUSIONS:Social and economic advantages of playing professional football did not appear to equalize race disparities in health.

Objective To evaluate the associations between personal use of permanent hair dyes and cancer risk and mortality. Design Prospective cohort study. Setting and participants 117 200 women enrolled in the Nurses’ Health Study, an ongoing prospective cohort study of female nurses in the United States. The women were free of cancer at baseline, reported information on personal use of permanent hair dyes, and were followed for 36 years. Exposure Status, duration, frequency, and integral use (cumulative dose calculated from duration and frequency) of permanent hair dyes. Age at first use and time since first use of permanent hair dyes. Main outcome measures Associations of personal use of permanent hair dyes with risk of overall cancer and specific cancers, and cancer related death. Age and multivariable adjusted hazard ratios and 95% confidence intervals were estimated by using Cox proportional hazard models. Results Ever users of permanent hair dyes had no significant increases in risk of solid cancers (n=20 805, excluding non-melanoma skin cancers; hazard ratio 0.98, 95% confidence interval 0.96 to 1.01) or hematopoietic cancers overall (n=1807; 1.00, 0.91 to 1.10) compared with non-users. Additionally, ever users did not have an increased risk of most specific cancers (cutaneous squamous cell carcinoma, bladder cancer, melanoma, estrogen receptor positive breast cancer, progesterone receptor positive breast cancer, hormone receptor positive breast cancer, brain cancer, colorectal cancer, kidney cancer, lung cancer, and most of the major subclasses and histological subtypes of hematopoietic cancer) or cancer related death (n=4860; 0.96, 0.91 to 1.02). Basal cell carcinoma risk was slightly increased for ever users (n=22 560; 1.05, 1.02 to 1.08). Cumulative dose was positively associated with risk of estrogen receptor negative breast cancer, progesterone receptor negative breast cancer, hormone receptor negative breast cancer, and ovarian cancer. An increased risk of Hodgkin lymphoma was observed only for women with naturally dark hair (based on 70 women, 24 with dark hair), and a higher risk of basal cell carcinoma was observed for women with naturally light hair. Conclusion No positive association was found between personal use of permanent hair dye and risk of most cancers and cancer related mortality. The increased risk of basal cell carcinoma, breast cancer (estrogen receptor negative, progesterone receptor negative, hormone receptor negative) and ovarian cancer, and the mixed findings in analyses stratified by natural hair color warrant further investigation.

Objective American‐style football (ASF) has gained attention because of possible links between repetitive head injury and neurodegenerative diseases. Although postmortem pathologic changes consistent with chronic traumatic encephalopathy (CTE) have been reported in ASF players, there are currently no established premortem diagnostic criteria for CTE. Nevertheless, presented with symptoms of cognitive impairment, clinicians treating former players may be inclined to suggest CTE without a thorough exploration of comorbid factors that demonstrate similar clinical phenotypes to putative CTE. Methods A survey of 3,913 former ASF players aged 24 to 89 was conducted for those who responded by March 2019. Results Despite being a postmortem diagnosis, 108 players (2.8%) self‐reported clinician‐diagnosed CTE. The percentage of players under age 60 years reporting a CTE diagnosis was 2.3% versus 3.7% in participants age 60 or older. Comorbidities in participants self‐reporting CTE were significantly more common, including sleep apnea, hypercholesterolemia, obesity, indicators of past or current depression, hypertension, prescription pain medication use, heart conditions, and low testosterone when compared to non‐CTE respondents. Patterns of reporting for obesity, hypertension, heart conditions, or hypercholesterolemia differed between older and younger participants. Cognitive impairment symptoms were significantly higher in participants self‐reporting CTE. Interpretation Some former professional football players have been clinically diagnosed with CTE, a postmortem condition. Comorbidities that can affect cognition were associated with CTE diagnoses in both older and younger players. Although underlying neuropathology cannot be ruled out, treatable conditions should be explored in former athletes demonstrating CTE‐linked clinical phenotypes or symptoms as a means of improving cognitive health in these patients. ANN NEUROL 2020 ANN NEUROL 2020;88:106–112

BACKGROUND:Exposure to disinfectants among healthcare workers has been associated with respiratory health effects, in particular, asthma. However, most studies are cross-sectional and the role of disinfectant exposures in asthma development requires longitudinal studies. We investigated the association between occupational exposure to disinfectants and incident asthma in a large cohort of U.S. female nurses.METHODS:The Nurses' Health Study II is a prospective cohort of 116 429 female nurses enrolled in 1989. Analyses included 61 539 participants who were still in a nursing job and with no history of asthma in 2009 (baseline; mean age: 55 years). During 277 744 person-years of follow-up (2009-2015), 370 nurses reported incident physician-diagnosed asthma. Occupational exposure was evaluated by questionnaire and a Job-Task-Exposure Matrix (JTEM). We examined the association between disinfectant exposure and subsequent asthma development, adjusted for age, race, ethnicity, smoking status, and body mass index.RESULTS:Weekly use of disinfectants to clean surfaces only (23% exposed) or to clean medical instruments (19% exposed) was not associated with incident asthma (adjusted hazard ratio [95% confidence interval] for surfaces, 1.12 [0.87-1.43]; for instruments, 1.13 [0.87-1.48]). No association was observed between high-level exposure to specific disinfectants/cleaning products evaluated by the JTEM (formaldehyde, glutaraldehyde, bleach, hydrogen peroxide, alcohol quats, or enzymatic cleaners) and asthma incidence.CONCLUSIONS:In a population of late career nurses, we observed no significant association between exposure to disinfectants and asthma incidence. A potential role of disinfectant exposures in asthma development warrants further study among healthcare workers at earlier career stage to limit the healthy worker effect.

Background: Former American football players have a higher prevalence of cognitive impairment than that of the US general population. It remains unknown what aspects of playing football are associated with neuropsychiatric outcomes. Hypothesis: It was hypothesized that seasons of professional football, playing position, and experience of concussions were associated with cognition-related quality of life (QOL) and indicators of depression and anxiety. Study Design: Descriptive epidemiology study. Methods: The authors examined whether seasons of professional football, playing position, and experience of concussions, as measured by self-report of 10 symptoms, were associated with cognition-related QOL and indicators of depression and anxiety in a cross-sectional survey conducted 2015 to 2017. Cognition-related QOL was measured by the short form of the Quality of Life in Neurological Disorders: Applied Cognition–General Concerns. The Patient Health Questionnaire–4 measured depression and anxiety symptoms. Of 13,720 eligible men with apparently valid contact information, 3506 players returned a questionnaire at the time of this analysis (response rate = 25.6%). Results: Seasons of professional play (risk ratio [RR] per 5 seasons = 1.19, 95% CI = 1.06-1.34) and playing position were associated with cognition-related QOL. Each 5 seasons of play was associated with 9% increased risk of indicators of depression at borderline statistical significance (P = .05). When compared with former kickers, punters, and quarterbacks, men who played any other position had a higher risk of poor cognition-related QOL, depression, and anxiety. Concussion symptoms were strongly associated with poor cognition-related QOL (highest concussion quartile, RR = 22.3, P < .001), depression (highest quartile, RR = 6.0, P < .0001), and anxiety (highest quartile, RR = 6.4, P < .0001), even 20 years after last professional play. Conclusion: The data suggest that seasons of play and playing position in the NFL are associated with lasting neuropsychiatric health deficits. Additionally, poor cognition-related QOL, depression, and anxiety appear to be associated with concussion in the long term.

Abstract Background The long‐term health consequences of participation in American style football (ASF) are not well understood. Methods We conducted a retrospective cohort study of men who had played in the NFL after 1960. Participants were studied using a standardized self‐administered questionnaire designed to determine both the exposure history to ASF and the prevalence of chronic pain, sleep apnea, cardiometabolic disease, and neurocognitive impairment. Logistic regression and negative binomial regression models were used to assess associations between age, ethnicity, body‐mass index during professional football career, field position, and football career duration with individual and multiple afflictions. Results In this cohort of former NFL players (n = 3745), approximately one quarter of the eligible former players (27%) reported two or more medical afflictions (chronic pain, cardiometabolic disease, sleep apnea, or neurocognitive impairment). Career duration was significantly associated with an increase in the number of comorbidities. Age, race, and body‐mass index were associated with all affliction categories, other than neurocognitive impairment, which was similarly prevalent in middle‐aged players and older players. Earlier age when first playing the sport was protective against cardiometabolic affliction. Conclusions Former NFL players report significant combinations of cross‐system afflictions. Future work will be required to determine mechanistic underpinnings. However, attention to the whole player, rather than specific organ systems seems critical to improve long‐term health outcomes in former ASF professional athletes.